Medicines for Rheumatoid

Arthritis
A Review of the Research for Adults
 Is This Information Right for Me?

Yes, this summary is for you if:

„„ Your doctor* has told you that you have rheumatoid (pronounced
ROOM-ah-toyd) arthritis (RA).
„„ Your doctor has suggested that you take one or more disease-
modifying anti-rheumatic drugs (DMARDs, pronounced
DEE-mardz) to treat your RA.
 Abatacept (Orencia®)  Infliximab (Remicade®)

 Adalimumab (Humira®)  Leflunomide (Arava®)

 Anakinra (Kineret®)  Methotrexate (Folex®,

 Certolizumab pegol
Rheumatrex®, Trexall®)
(Cimzia®)  Rituximab (Rituxan®)

 Etanercept (Enbrel®)  Sulfasalazine (Azulfidine

 Golimumab (Simponi®)
EN-Tabs®, Sulfazine®)
 Tocilizumab (Actemra®)
 Hydroxychloroquine
(Plaquenil®)

„„ Your doctor has suggested you take a corticosteroid together

with a DMARD to treat your RA.
 Methylprednisolone (Depo Medrol®, Medrol®, Solu-Medrol®)

 Prednisolone (Delta-Cortef ®, Econopred®, Orapred®,

Pediapred®, Prelone®)
 Prednisone (Deltasone®, Liquidpred®, Sterapred®)

„„ You want to know what research says about the benefits and
side effects of these medicines.

* In this summary, the term “doctor” refers to the health care professionals who may
take care of you, including your physician, rheumatologist, nurse practitioner, or
physician assistant.
This summary is not for you if:
„„ You have a type of arthritis other than RA, such as osteoarthritis.
„„ Your doctor has not suggested that you take DMARDs or
corticosteroids for your RA.
„„ You are under age 18. This information is from research on adults.

What will this summary tell me?

This summary will tell you about two types of medicine to treat RA:
DMARDs and corticosteroids. It will explain what research has found
about how well DMARDs work when taken alone or with corticosteroids
to treat RA. It will also tell you what research says about the side effects
of these medicines. You can use this summary to talk with your doctor
about whether one of these medicines may be right for you.

Where does the information come from?

Researchers funded by the Agency for Healthcare Research
and Quality (AHRQ), a Federal Government research agency,
reviewed 211 studies on medicines for RA published between
January 1990 and January 2011. The report was reviewed by
clinicians, researchers, experts, and the public. You can read the
report at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.

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 Understanding Your Condition

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a disease that causes pain, swelling,
and stiffness in the joints. In some people, it can also cause the
joints to become damaged and deformed.
„„ Although it can affect any joint in the body, RA is most commonly
found in the hands, wrists, feet, and knees. Usually, if it is found in
one hand, it will appear in the other as well.
„„ Sometimes RA can cause problems with body parts other than your
joints such as your heart, lungs, eyes, or mouth.
„„ RA usually lasts many years or an entire lifetime. For some people,
RA can last for only a few months to a few years with treatment,
although this is rare.
„„ The symptoms of RA (pain, swelling, stiffness) can get worse for
some periods of time (called a “flareup”) and then get better for
some periods of time.

Normal Hand with

hand rheumatoid
arthritis

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What causes RA?
The cause of RA is unknown, but researchers think the condition may
be passed down in families. The pain and symptoms of RA happen
when your immune system (the system of the body that helps defend
you from germs) attacks the healthy lining of your joints. Doctors are
not sure why the immune system in some people attacks their joints.
How common is RA?
„„ RA is less common than other kinds of arthritis such as osteoarthritis.
„„ More than 1 million people in the United States have RA.
„„ Women are more likely to have RA than men. About 7 out of every
10 people with RA are women.
„„ Although RA can happen at any age, it usually develops between
ages 30 and 50.
How can treatment help?
Although there is no cure for RA, treatment can:
„„ Relieve pain and swelling
„„ Slow down or stop joint damage
„„ Help lower the number of symptom “flareups” (times when pain or
swelling is the worst)
„„ Improve your ability to do daily activities such as bathing, getting
dressed, doing chores, reaching, and lifting
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What medicines are used to treat RA?
RA is treated with several different types of medicines, including:
„„ Pain relievers: Over-the-counter medicines such as aspirin,
acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), or
naproxen (Aleve®)
„„ Corticosteroids: Medicines that can relieve RA pain and swelling
for a little while
„„ Disease-modifying anti-rheumatic drugs (DMARDs): Medicines
that can decrease symptoms, slow or stop joint damage, and improve
your ability to do daily activities
Sometimes DMARDs and corticosteroids are taken together to treat
RA. This summary looks at the research on how well DMARDs
work when taken alone or with corticosteroids.

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 Understanding Your Options

What are DMARDs?

DMARDs are a family of medicines that stop the body’s immune
system from attacking and destroying joints. If you have severe
RA symptoms or are not getting enough relief from pain relievers
or corticosteroids, your doctor may suggest a DMARD. DMARDs
may be taken with each other or together with pain relievers
and corticosteroids.
There are two kinds of DMARDs: nonbiologic and biologic.
Nonbiologic DMARDs
Like most medicines, nonbiologic DMARDs are produced from
chemicals. They are usually taken daily or weekly as pills, but some
can also be given as shots. Nonbiologic DMARDs include:
„„ Hydroxychloroquine „„ Methotrexate (Folex®,
(Plaquenil®) Rheumatrex®, Trexall®)
„„ Leflunomide (Arava®) „„ Sulfasalazine (Azulfidine
EN-Tabs®, Sulfazine®)
Biologic DMARDs
Biologic DMARDs are proteins similar to those made in your
body, but these proteins are created in laboratories. Biologic
DMARDs must be given as shots or through an IV (intravenous)
tube into a vein in your arm. Biologic DMARDs include:
„„ Abatacept (Orencia®) „„ Etanercept (Enbrel®)
„„ Adalimumab (Humira®) „„ Golimumab (Simponi®)

„„ Anakinra (Kineret®) „„ Infliximab (Remicade®)

„„ Certolizumab pegol „„ Rituximab (Rituxan®)

(Cimzia®) „„ Tocilizumab (Actemra®)

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Some biologic DMARDs such as infliximab (Remicade®), rituximab
(Rituxan®), and tocilizumab (Actemra®) must be given through an IV
tube at a doctor’s office or clinic. This could take up to 2 hours. Other
biologic DMARDs come in injection pens that you can use at home.
Most biologic DMARDs are given once a month, once every other
week, or once a week. Your doctor may change your schedule
depending on how well you are doing.
What are the possible side effects of nonbiologic and
biologic DMARDs?
Because nonbiologic and biologic DMARDs work in different
ways, they have different side effects, some of which are serious.

Possible Side Effects of DMARDs

Nonbiologic DMARDs Biologic DMARDs
Upset stomach
„„ Mouth sores
„„ Redness, swelling,
„„ Sinus infection
„„
Nausea
„„ Rash or serious skin
„„ itching, bruising, (sore throat, runny
Diarrhea
„„ reactions or pain in the area nose, hoarseness)
Hair loss
„„ Liver, kidney, or lung
„„ where the shot Headache
„„
problems was given Nausea
„„
Diarrhea
„„

Possible Serious Side Effects

In rare cases, the nonbiologic DMARD methotrexate and some biologic DMARDs (including
„„
adalimumab [Humira®], etanercept [Enbrel®], golimumab [Simponi®], and infliximab [Remicade®])
have been associated with:
…… Serious infections such as tuberculosis (called “TB”), fungal infections such as yeast, pneumonia,
or food-borne illnesses such as listeria
…… Cancer, usually lymphoma (cancer in the lymph glands, which are part of the immune system)
The risk of serious infections or cancer is increased by taking two or more biologic DMARDs together
„„
or by taking a biologic DMARD with a nonbiologic DMARD. The exact risk to people with RA who are
taking a DMARD is not known.
Rituximab (Rituxan®) can cause a severe reaction the first time you take it. It could also cause a
„„
life-threatening rash.
This information comes from the U.S. Food and Drug Administration (FDA) labels of these medicines.

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What are corticosteroids?
Corticosteroids are a kind of medicine that works like a certain type
of hormone in your body. Corticosteroids can help reduce swelling
and stop the body’s immune system from attacking healthy joints.
Corticosteroids are taken as pills, liquids, or shots and include:
„„ Methylprednisolone (Depo Medrol®, Medrol®, Solu-Medrol®)
„„ Prednisolone (Delta-Cortef ®, Econopred®, Orapred®, Pediapred®,
Prelone®)
„„ Prednisone (Liquidpred®, Deltasone®, Sterapred®)
What are the possible side effects of corticosteroids?
Possible side effects of corticosteroids listed by the FDA include:
„„ Swelling in the lower legs „„ Mood swings
„„ Weight gain „„ Increased pressure
„„ Increased blood pressure in the eyes

Possible side effects from taking corticosteroids for longer than a few
days or weeks include:
„„ High blood sugar, which „„ Irregular menstrual periods
can cause or worsen diabetes „„ Thin skin that bruises easily
„„ Increased risk of infections „„ Longer time for wounds
„„ Loss of calcium from to heal
bones, which can make
it easier to break a bone
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What does research say about nonbiologic DMARDs?
How well they work to treat RA:
„„ Methotrexate (Folex®, Rheumatrex®, Trexall®) and sulfasalazine
(Azulfidine EN-Tabs®, Sulfazine®) work about the same to reduce
symptoms, reduce the number of joints affected, improve the ability
to do daily activities, and slow down or stop joint damage.
„„ Leflunomide (Arava®) appears to work about as well as methotrexate,
but there is not enough research to know this for certain.
Side effects:
„„ All nonbiologic DMARDs appear to cause about the same
amount of side effects, but there is not enough research to know
this for certain.
What does research say about biologic DMARDs?
How well they work to treat RA:
„„ Biologic DMARDS work to decrease or completely stop
symptoms, improve the ability to do daily activities, and slow
down or stop joint damage.
Side effects:
„„ Taking a biologic DMARD increases the risk of developing
serious infections.
„„ Taking biologic DMARDs for long periods of time does not
increase the risk of having serious side effects.
What does research say about combining medicines?
How well they work to treat RA:
„„ If treatment with one DMARD does not relieve symptoms, taking
a biologic DMARD together with the nonbiologic DMARD
methotrexate works better than taking only one to improve the
ability to do daily activities and slow down or stop joint damage.

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„„ Adding a corticosteroid to treatment with a nonbiologic DMARD
improves the ability to do daily activities more than taking a
nonbiologic DMARD alone. Adding a corticosteroid may also slow
down or stop joint damage more than taking a nonbiologic DMARD
alone, but there is not enough research to know this for certain.
„„ For people who have had RA for less than 3 years, taking two or
three nonbiologic DMARDs plus a corticosteroid works better
than taking only one nonbiologic DMARD.
„„ For people who have had RA for less than 3 years, taking the
nonbiologic DMARD methotrexate together with a biologic
DMARD decreases or completely stops symptoms and slows
down or stops joint damage in people whose RA was quickly
getting worse.
„„ For people who have had RA for a long time without any
improvement, taking three nonbiologic DMARDs together
reduces symptoms and the number of joints affected more than
taking one or two nonbiologic DMARDs.
Side effects:
„„ Taking a nonbiologic DMARD with a biologic DMARD does not
cause more side effects than taking the biologic DMARD alone.
„„ Taking two or more biologic DMARDs together can cause more
serious side effects than taking only one.
„„ Taking a corticosteroid together with a nonbiologic DMARD
does not make treatment more difficult to tolerate.
„„ In people who have had RA for less than 3 years, taking two
or three nonbiologic DMARDs plus a corticosteroid does not
make treatment more difficult to tolerate than taking only a
nonbiologic DMARD.

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What does research say about how nonbiologic and
biologic DMARDs compare to each other?
How well they work to treat RA:
„„ The biologic DMARDs adalimumab (Humira®) and etanercept
(Enbrel®) help decrease symptoms about the same as the nonbiologic
DMARD methotrexate.
Side effects:
„„ There is not enough research to know if certain side effects happen
more often with nonbiologic or biologic DMARDs.

Making a Decision

What should I think about when deciding?

More research is needed to know which RA medicines might work
best for different people. There are several things to consider when
choosing a medicine to treat your RA:
„„ The trade-offs between the possible benefits and side effects for
each medicine
„„ Which medicine best fits your lifestyle, what is important to you
(your values), and your preferences
…… You may want to think about how comfortable you are with
taking pills, getting shots, or taking the medicine through an IV
tube. You may also want to consider how often you are able to go
to the doctor’s office or clinic and how much time you are able to
spend there.
„„ The cost of each medicine

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What are the trade-offs?
Only you and your doctor can decide whether taking a DMARD
for your RA is worth the risk of possible side effects. You and your
doctor should discuss:
„„ The amount of pain or joint damage you have and whether
treatment with a DMARD can help
„„ The risk of serious side effects from DMARDs

„„ Signs to look for to help you notice serious side effects so they
can be treated or so your medicine can be changed
„„ Whether adding a corticosteroid to your treatment with
DMARDs might help
„„ Other options besides DMARDs that might help your RA

What are the costs?

The costs to you for nonbiologic and biologic DMARDs and
corticosteroids depend on:
„„ Your health insurance plan „„ Whether a generic form of
„„ The amount (dose) you need the medicine is available
„„ Whether you take the medicine „„ Whether the company that

as a pill, as a shot, or through makes the medicine offers

an IV tube financial help to lower the cost

Corticosteroids can be taken for short periods of time (30 days) or

longer, depending on your specific needs. The cost for corticosteroids
is around $3 to $15 a month. The cost to you depends on how much
of the medicine you need and how long you will need to take it.

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Wholesale Prices: Nonbiologic and Biologic DMARDs

Drug Name Brand Name Price per Month* Form Dose

Nonbiologic DMARDs
Generic $35–$75
Hydroxychloroquine Tablet 200–400 mg daily
Plaquenil® $110–$215
Generic $490
Leflunomide Tablet 20 mg daily
Arava® $910
Generic $45–$90
Methotrexate Folex®, Rheumatrex®, Tablet 7.5–15 mg weekly
$125–$140
Trexall®
Generic $40
Sulfasalazine Azulfidine EN-Tabs® $120 Tablet 2,000 mg daily
Sulfazine® $30
Biologic DMARDs (Generic versions of these medicines are not available.)
$1,430–$2,860 IV 500–1,000 mg monthly
Abatacept Orencia®
$2,530 Shot 125 mg weekly
40 mg twice
Adalimumab Humira® $2,450 Shot
a month
Anakinra Kineret® $2,760 Shot 100 mg daily
Certolizumab pegol Cimzia® $2,360 Shot 400 mg monthly
Etanercept Enbrel® $2,475 Shot 50 mg weekly
Golimumab Simponi® $2,650 Shot 50 mg monthly
200–500 mg twice a
Infliximab Remicade® $3,725–$9,300 IV month (depending
on your weight)
Rituximab Rituxan® $15,180 IV 1,000 mg twice a month
400–800 mg monthly
Tocilizumab Actemra® $1,660–$3,320 IV (depending on
your weight)
* Prices are the average wholesale prices from RED BOOK Online® rounded to the nearest $5. Generic prices
are the middle value in the range of prices listed from different manufacturers. The actual prices of the
medicines may be higher or lower than the prices listed here, depending on your health insurance and the
manufacturer used by your pharmacy.
IV = intraveneous

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Ask your doctor
„„ Do you think a DMARD could help my RA?
„„ What serious side effects should I look for?
„„ Would adding a corticosteroid to a DMARD help my RA?
„„ How long will it take until I start to feel better?
„„ Is there a less expensive medicine that I could take?
„„ What else can I do to help my RA?
„„ Are there specific lifestyle changes you can suggest that might help?

Other questions for your doctor:

Write the answers here:

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Source

The information in this summary comes from the report Drug Therapy
for Rheumatoid Arthritis in Adults: An Update, April 2012.
The report was produced by the RTI International–University of North
Carolina Evidence-based Practice Center through funding by the
Agency for Healthcare Research and Quality (AHRQ). For a copy of the
report or for more information about AHRQ and the Effective Health
Care Program, go to www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Additional information came from the MedlinePlus® Web site, a service
of the National Library of Medicine and the National Institutes of
Health. This service is available at www.nlm.nih.gov/medlineplus.
This summary was prepared by the John M. Eisenberg Center for
Clinical Decisions and Communications Science at Baylor College
of Medicine, Houston, TX. Patients with rheumatoid arthritis
reviewed this summary.

AHRQ Pub. No. 12(13)-EHC025-A

November 2012